ELSEVIER CASE REPORT BILATERAL GIANT ABDOMINOSCROTAL HYDROCELES IN CHILDHOOD SCOTT SERELS AND STANLEY KOGAN ABSTRACT There is a paucity of cases in the literature describing the abdominoscrotal hydrocele (ASH). We report the diagnostic and therapeutic aspects of a rapidly expanding giant bilateral ASH in a 4-month-old boy. UROLOGY ® 47: 763-765, 1996. R eports describing examples of giant abdomi- noscrotal hydroceles (ASHs) in children are few. It was Dupytren in 1834 who first described this conditionl; however, it was not until 1919 that this entity received its present name--ASH. 2 Although this type of hydrocele has been known for more than a century, less than 20 cases have been reported in children. 3 In fact, it was not until 1988 that the first bilateral ASH was reported in a child. 4 CASE REPORT A 4-month-old, otherwise healthy, male infant was referred for evaluation of a congenital scrotal swelling. On physical examination, a large left in- guinal scrotal hydrocele and a moderately sized right scrotal hydrocele were noted. The patient was then seen again at 7 months of age, and the left hydrocele was appreciably larger. The abdom- inal examination was unremarkable at this time, and no voiding abnormalities were present. Sur- gical repair was therefore scheduled due to the sig- nificant enlargement. Six weeks later at the time of anesthesia induction, a large abdominal mass was noted that extended 2 cm above the umbilicus (Fig. 1). This mass had not been present previ- ously and did not reduce on insertion of a bladder catheter. Cystoscopy and a cystogram were per- formed. Normal bladder mucosa and a normal tri- gone were found; however, there was a left lower quadrant mass indenting the bladder. An ultra- From the Department of Urology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York Reprint requests: Stanley Kogan, M.D., 311 North Street, Suite 310, White Plains, NY 10605 Submitted: October 16, 1995, accepted: November 10, 1995 sound revealed normal kidneys without evidence of hydronephrosis, but there was a supravesical mass that appeared to be contiguous with the blad- der (Fig. 2). Five days after the first procedure, an explora- tion through a midline incision revealed a 15 x 15 cm hourglass-shaped mass that composed the left abdominoscrotal hydrocele (Fig. 3 ). The right hydrocele extended intra-abdominally as well but was less prominent. The right testicle was noted to be significantly larger than the left testicle, which was intra-abdominal and appeared long, tu- bular, and dysplastic. The left epididymis was not identifiable. The left vas deferens was displaced into the right pelvis by the enlarged left hydrocele and was divided during the dissection. Both testes were biopsied, and frozen sections revealed "im- mature testes." Bilateral hydrocelectomies with re- moval of the intra-abdominal components and bi- lateral orchiopexies were performed. The patient has done well postoperatively without evidence of recurrence. COMMENT An ASH consists of a scrotal and a large intra- peritoneal or retroperitoneal hydrocele compo- nent that connects in an hourglass fashion at the internal ring. The etiology of the ASH is conjec- tural. There are two leading theories: (1) The hy- drocele is pushed back from the scrotum through the inguinal canal into an extraperitoneal intra- abdominal site2; and (2) the distension starts very high intra-abdominally and extends through the inguinal canal into the scrotum, s Both these the- ories rely on the concept of a partially obliterated processus vaginalis, which serves as a one-way valve so that episodes of high intra-abdominal COPYRIGHT 1996 BY ELSEVIER SCIENCE INC. 0090-4295/96/$15.00 ALL RIGHTS RESERVED PII S0090-4295(96)00022-2 763